Home > Back to Publisher > Report Information

Medical Review Criteria for Managing Care

Apollo Managed Care Consultants
January 2, 2011
1255 Pages - SKU: APO6065653

Abstract Table of Contents Related Reports

This report consists of more than 1,600 evidence-based clinical review criteria guidelines listing specific reasonable and necessary indications & criteria for ambulatory or inpatient care, tests, referrals and procedures. Comprehensive coverage information. Length of stay benchmarks. Payment criteria. Extensive authoritative references. “The Bible” for health plan and Medicare benefit interpretations. Critical resource for provider education and claims management, as well as traditional UM. The most comprehensive review criteria guideline resource available.

Introduction: Introduction to evidence-based authorization management guidelines and criteria; CMS national policies; Levels of risk in capitation; Basic elements of a utilization management plan; Consultations vs. referrals; Guidelines; ‘Evaluate and Treat’ orders and authorization requests; Medical Necessity - What is it?; Case law citations related to medical necessity; AHRQ Prevention Quality Indicators; Speed up the review process by …; Hospital Inpatient Admission Criteria, general principles; ‘Automatic’ approval of authorization requests; Medical error coverage; Health and behavior assessments assessment

Allergy: Allergic rhinitis - Rhinophototherapy, Referral criteria; Allergy referral; Allergy testing and desensitization therapy; Serial Endpoint Allergy Testing; Asthma; Immunotherapy for malignant disease; Leukocyte Histamine Release Test (LHRT);

Food allergies: Food allergy testing and therapy; Challenge testing for food allergies; Screening for Hypersensitivity Reactions to Foods and Chemicals, In Vitro Particle Size Measurement;

Nasal Challenge Test; Omalizumab (Xolair®); Transfer factor; Allergy notes.

Alternative & Complementary Medicine (CAM) Alternative medicine criteria; Acupuncture/Acupressure; Applied Kinesiology; Aromatherapy; Ayurvedic medicine; Biofeedback; Biofeedback for Urinary Incontinence; Magnetic and Bioelectromagnetic Therapy; Diet and Nutrition; Guided imagery; Homeopathy; Hypnotherapy; Manual/massage therapy; Naturopathy; Relaxation therapy; Transcendental meditation; Yoga;

Alternative medicine resources; references; web sites; resource organizations - list; CAM notes.

Anesthesiology/Pain Medicine Review criteria and payment guidelines: Anesthesia services - General Coverage Policy; Anesthesia for pacemaker implantation; Office-based anesthesia; Bispectral Index Monitor; Dental Anesthesia; Safe sedation of children; Intraoperative Awareness - Monitoring;

Pain Management: Cryoanalgesia; Cold Laser (low-energy or low-level) Therapy for wound healing, pain therapy, and other disorders; Pulsed Radiofrequency for Pain Management;

Nerve blocks: Intrathecal/subarachnoid injections; Epidural injections for pain; Celiac plexus nerve blocks; Continuous epidural analgesia; Facet Joint Injections/Median Branch Nerve Blocks; Intercostal nerve blocks; Paravertebral Nerve Blocks; Percutaneous alcohol injections for the ablation of intractable pain; Transforaminal epidural injections; Anesthesiology Notes.

Blood Bank:

Autologous Blood-Derived Products for Chronic Non-Healing Wounds; Blood transfusions; autologous, allogeneic, donor directed; Cord blood storage; Granulocyte and Platelet Transfusions; Plasmapheresis, Extracorporeal photopheresis for Crohn’s disease; plasma exchange, apheresis and related procedures; Lipid apheresis;

Nonselective (random) transfusions and living-related donor specific transfusions in kidney transplantation; Operative blood salvage; Therapeutic Phlebotomy; Blood bank notes.

Cardiology: Acoustic Heart Scans/Recordings; Ambulatory blood pressure monitoring; Ambulatory electrocardiography (Holter monitor); Arterial elasticity as a screening tool for CV disease; Atrial fibrillation - ablative procedures; Brachytherapy, Coronary; Cardiology consultation or referral; Chest pain - admission criteria, Cardiac catheterization, right heart; Central venous pressure monitoring, Cardiac Catheterization, right heart, Central venous pressure monitoring; Cardiac Catheterization, left heart; Coronary Arteriography; Angiography and Ventriculography;

Ambulatory Cardiac Event Monitors, Esophageal Doppler Monitoring, Holter monitors; Real Time Cardiac Surveillance System - Loop Recorders; Implanted Loop Recorders; Mobile Cardiac Outpatient Telemetry (MCOT); Catheter ablation for atrial fibrillation with HF;

Cardiac Output (CO) Measures, noninvasive; Electrical bioimpedance, thoracic; Inert gas re-breathing techniques; Doppler monitor;

Cardiovascular Nuclear Medicine studies; Congestive Heart Failure - admission, discharge criteria guidelines; CT scans to screen for coronary artery disease; Defibrillator devices: automatic implantable and wearable external cardioverter; Home defibrillators; Direct current cardioversion, elective; Directional coronary atherectomy (DCA); Displacement cardiography/cardiokymography and photokymography;

Echocardiograms, adult and pediatric; Doppler Echocardiography; Stress Echocardiography; Electrocardiograms; Cardiointegram (CIG); EKGs correlated with Acoustic Heart Sounds; Body Surface Potential Mapping; Electrophysiology testing (ET); His bundle studies; Endocardial electrical recording and stimulation (EES), diagnostic;

Enhanced external counterpulsation (ECP) - treatment for severe angina; Exercise Treadmill Test (ETT), routine screening; Exercise Treadmill Test (ETT) - routine, screening; ETT with Thallium imaging; Left ventricular end diastolic pressure (LVEDP) measurement in the outpatient setting.

Pacemakers - permanent cardiac/Resynchronization Therapy; Pacemaker monitors; Pacemakers/External manually activated devices to terminate tachyarrhythmias; Percutaneous Transluminal Coronary Angioplasty (PTCA); Pulmonary Artery Hypertension (PAH) - Iloprost therapy, Prostacyclin infusions; Radiofrequency Catheter Ablation; Stents, coronary artery; Stents, venous; Thoracic electrical bioimpedance; Thrombolysis for acute myocardial infarction; Tilt Table Testing; T-Wave Alternans (TWA) testing; Vascular cryoplasty;

Cardiac Rehabilitation Programs; Phonocardiography and Vectorcardiography; LOS benchmarks/targets for cardiology diagnoses; References re: AMI LOS; Screening for cardiac disease; Cardiology guideline resources, Web links; Referrals; Cardiology notes.

Cardiovascular/Thoracic/Peripheral Vascular Surgery: Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy; Angioplasty Aorta (for aortic stenosis); Aortic Aneurysm Repair - Criteria and Options; Fabric Wrapping of Abdominal Aneurysms; Aortic valve repair and/or replacement; Artifical heart and related; Atherectomy, peripheral; Atrial fibrillation - ablative procedures; Atrial septal defect, repair; Autologous cell therapy for damaged myocardium;

Carotid body tumor resection (Glomectomy); Carotid sinus stimulation; Carotid endarterectomy - Indications, LOS; Carotid/Vertebral Artery Angioplasty and Stenting Procedures; Coronary artery bypass graft(s) surgery (CABG)/Off Pump or Beating Heart CAB - Indications, LOS; Cryoplasty, peripheral arterial

Dynamic cardiomyoplasty; Extracranial-Intracranial arterial bypass surgery; Heart transplant; Heart volume reduction surgery (partial ventriculectomy); Heartsbreath test for cardiac transplant rejection

Impedance plethysmography; Intermittent claudication; Intraoperative Ventricular Mapping; Left Ventricular Assist Devices; Maze Procedure for atrial fibrillation/flutter; Microsurgical lymphaticovenous anastomosis operation for lymphedema; Mitral valve repair and/or replacement;

Patent ductus arteriosus - closure; Patent foramen ovale - closure ; Pectus excavatum and Pectus carinatum - Surgical Correction; Percutaneous radiofrequency ablation for primary and secondary lung cancers; Photophoresis, extracorporeal - Therapy for Heart Transplant Rejection; Post-thoracotomy Pain - Intraoperative, Intercostal Nerves, Cryoanalgesia; Pulmonary vein isolation for atrial fibrillation; Pulmonary valve repair and/or replacement;

Peripheral vascular percutaneous interventional procedures; Cryoplasty; Peripheral vascular rehabilitation; Pseudoaneurysms, Thrombin injection; Pulmonary arterial shunts - balloon angioplasty

Renal Artery Stenosis - Angioplasty, Stent Placement; Robotically-assisted cardiac surgery; Stents; Thoracoscopic aortopexy for tracheomalacia

Thrombectomy, arterial or venous; Mechanical embolectomy for acute ischemic stroke; Total Artificial Heart Replacement; Transcoronary ablation of septal hypertrophy (TASH); Transjugular Intrahepatic Portosystemic Shunt; Transmyocardial laser revascularization; Tricuspid valve repair and/or replacement;

Valvular heart disease - repair and/or replacement guidelines by valve;

Varicose vein/Perforator vein procedures including Endovenous RadiofrequencyAblation Therapy, Sclerotherapy, Endoscopic perforator vein ligation; Venous stents;

Ventricular Assist Devices; Ventricular Reduction/Remodeling or Partial Ventriculectomy; Ventricular Septal Defect (VSD); Vertebral artery surgery; Cardiovascular/Peripheral vascular surgery resource links, notes.

Dermatology: Dermatology referral management; Acne vulgaris treatment, referral criteria - including phototherapy; Actinic keratosis including laser and photodynamic therapy guidelines; Alopecia areata; Atopic dermatitis; Basal cell carcinoma; Biopsy/excision of benign skin and subcutaneous lesions, Cellulitis; Contact dermatitis; Cysts involving the skin and subcutaneous structures;

Decubitus Ulcers, treatment; Dermatoscopy/Digital Epiluminescence Microscopy (DELM)/Skin Surface Microscopy/Total Body Photography; Fungus infections, skin and nails; Dermatophytosis; Grenz Ray Therapy; Herpes Simplex; Herpes Zoster;

Hyperhidrosis therapy; Impetigo and pyoderma; Inflammatory dermatosis/’Rashes’; Hair Loss/Alopecia; Keloids; Laser for actinic lesions;

Malignant melanoma; Isolated limb perfusion for malignant melanoma in an extremity; Melanoma vaccines;

Mohs Micrographic Surgery; Pediculosis (‘lice’); Photochemotherapy for the treatment of scleroderma, extracorporeal; Photodynamic therapy with aminolevulinic acid; Pityriasis rosea;

Psoriasis therapies and referral criteria; PUVA Therapy for Psoriasis; Alefacept Therapy for Psoriasis; Etanercept and Infliximab for Psoriasis in Adults

Rosacea; Scabies; Seborrheic dermatitis/’Dandruff’; Seborrheic keratosis; Squamous cell carcinoma; Tattoos; Telangectasia, Verruca Vulgaris/ Warts; Vitiligo; Ultraviolet A Light Therapy; Ultraviolet B Light Therapy; Dermatology notes.

Disposable Medical Supplies/Durable Medical Equipment: Definitions; Medicare Coverage Criteria

Disposable Medical Supplies (DMS)

Incontinence supplies; Porcine Skin and Gradient Pressure Dressings; Ostomy supplies; Surgical dressings; Tracheostomy care supplies; Unna boot; Urological supplies.

Durable Medical Equipment (DME)

Acne treatment heat devices; Anodyne® (near-infrared) therapy for peripheral neuropathy or any condition; ArtAssist® device for severe PAD; Bathroom and Toilet Equipment and Supplies;

Beds/Support Surfaces: Pressure Reducing Support Surfaces, Groups 1, 2, and 3; Air Fluidized Beds; Hospital-type Beds and Bed Accessories/Trapeze Bars; Bed and Pillow Covers for Asthmatics; Bed-wetting Alarm;

Breast Pumps; Catheters, urinary; Cervical collars; Chairs, therapeutic; Communication devices/aides; Compression Garments in the Treatment of Venous Stasis Ulcers; Continuous Passive Motion device; Cooling devices, external; Cranial Remodeling Band/Helmet for infants; Dermal thermometers, Diathermy;

Traction: Cervical traction; Lumbar traction; Vertebral decompression therapy; Gravity lumbar reduction chairs;

Diabetes mellitus-related DME - Glucose monitors, blood; Continuous glucose monitoring; GlucoWatch® Biographer - automatic glucose values without a needle-stick; Insulin Syringes; Insulin pens; Jet Injectors for insulin administration; Sleep sentry to detect hypoglycemia;

Electrical Stimulation DME: Dorsal Column Stimulators/Spinal Cord Stimulators: Chronic pain, Angina pectoris; Treatment of Motor Function Disorders with Electric Nerve Stimulation; Functional electrical stimulators; Neuromuscular electrical stimulation (NMES) for disuse atrophy; Neuromuscular or Therapeutic Electrical Stimulation (TES); Transcutaneous electrical nerve stimulation (TENS); ‘Sympathetic Therapy’; Inferential current stimulation; Non-implantable Pelvic Floor Electrical Stimulator; Percutaneous electrical nerve stimulation (PENS); ReliefBand; Implanted Peripheral Electrical Nerve Stimulation; Pulsed electrical stimulation for osteoarthritis of the knee;

Wound care: Autologous blood-derived products for non-healing wounds; Electrical Stimulation for the Treatment of Wounds; Chronic Stage III & IV Musculo-Cutaneous Ulcerations;

Surface electrical muscle stimulation; Bone stimulators: electrical and low-intensity ultrasound; Electrogalvanic Stimulators for Levator Syndrome; H-wave stimulation for the treatment of diabetic neuropathy; Low Frequency Ultrasound Wound Therapy;

Elastic garments, non-covered; Environmental Control Systems; Vaporizers; Exercise Equipment; End diastolic pneumatic compression boot/Circulator boot: for peripheral vascular disease or lymphedema; Hearing aids; Bone-anchored Hearing Aid; Hip protectors; Hospital beds; Infusion pumps; external or implantable; Jobst Burn Garments;

Lifts - seat and patient;

Light Emitting Diode (LED) or Infrared Therapy; Light therapy/phototherapy for seasonal affective disorder; Lymphedema 'Pump'/Manual lymph drainage; Magnetic Pelvic Floor Stimulation (MPFS); Nebulizers; Wound Care; Negative pressure wound therapy (NPWT) Pumps; Radiant Heat Wound Therapy Systems; Neuromuscular electrical stimulation (NMES);

Orthotic/prosthetic devices; Auricular prosthesis; Breast prosthesis, specialized bras for women post-mastectomy; Canes and crutches; Corset Used as Hernia Support; Dynamic Splinting Devices; Facial prostheses; Foot orthotics/therapeutic shoes/Footwear; Hand neuroprosthesis; Hernia Truss/Sykes; Knee braces; Magnetic insoles for plantar heel pain; Magnetic Pelvic Floor Stimulation (MPFS); Myoelectric prosthesis, upper extremity; Arm brace, robotic for post-stroke; Phototherapy for neonatal hyperbilirubinemia; Computerized lower limb prostheses, above-knee; Prosthesis criteria: functional levels; Prosthetic implants; Scoliosis braces; Shoe inserts to relieve back pain in patients with leg length discrepancies; Spinal Orthoses - TLSO, LSO; Spinal Unloading Devices; Splints, Strapping & Casting; TED/Support hose coverage; Prosthetics & orthotics ordered in a hospital or home prior to a skilled nursing facility admission - payment issues

Pulmonary DME: Airway Clearance/High Frequency Chest Wall Oscillation Devices; Carbon dioxide monitors; Heat Treatments - including diathermy and ultrasound for pulmonary conditions; Intrapulmonary Percussive Ventilator (IPV); Mechanical in-exsufflation/in-exsufflator devices; Nebulizers; Oxygen coverage guidelines; Home oxygen; Travel oxygen; Peak expiratory flow meters; Postural drainage boards; Respiratory Assist Devices; Suction pumps; Thairapy Ò vest for cystic fibrosis; Thairapy Bronchial Drainage System; Vaporizers

Pneumatic Compression Therapy - End-diastolic for non-healing extremity ulcers; Computerized lower limb prostheses; Prothrombin Time Home Testing Systems; Safety items - coverage;

Robotic-assisted rehabilitation of the upper limb after stroke;

Speech - Communication DME: Augmentive Communication Aides, Communication boards; Speech aids, electronic;

Standers, Boards and Tables; Therabite Jaw Motion Rehabilitation System; Vacuum therapy as a treatment for female sexual dysfunction; Vitrectomy Face Support; Wigs; Reuse Information Notice.

Mobility: INDEPENDENCE iBOT 4000 Mobility System; Strollers for special needs children; Walkers/Safety rollers; Wheelchairs, Power-type and Power-operated vehicles (POVs);

DMS/DME Miscellaneous Items List - a grid listing 275 additional DME/DMS items with related review recommendations to approve or deny coverage on the basis of medical necessity; DMS/DME notes.

Educational materials:

General educational materials, Patient Education Materials Policy - Development, Approval and Review, Institutional and Home Care Patient Education Programs; Medical ‘Self Care’ Educational Programs; Education classes for OB patients; The 'Not Now!' Program; Institutional and Home Care Patient Education Programs; Medicare Coverage of Diabetes Self-management Training; Renal disease educational services coverage; Smoking cessation programs; Education notes.

Emergency medical services: Emergency services/authorization system, Medicare Emergency Department (ED) Services Coverage Criteria for Claims; Emergency room authorization/claims processing matrix, Emergency treatment criteria; Relationship of ER admissions to insurance status; Ambulance and other medical transportation; EM notes.

ENT, Oral Surgery and Dental Services:

Acoustic neuroma; Ankyloglossia (tongue-tie); Audiological Testing; Auditory Brain Stem Implants; Aural Rehabilitation Therapy; Brain stem auditory evoked response (BER, BAER); Carbogen Inhalation Therapy for the Treatment of Sudden Hearing Loss; Cerumen (ear wax) removal; Cleft lip/Cleft Palate Repairs; Cochlear Implantation; Cochleostomy with neurovascular transplant;

Obstructive Sleep Apnea (OSA): Acoustic pharyngometry (EccovisionTM Acoustic Pharyngometer); SNAPTM Testing System; CPAP for obstructive sleep apnea; Noninvasive Positive Pressure/Bi- PAP; Oral Appliances for Snoring; Palatal implants/Pillar Procedure for OSA; Osteotomy (maxillary, mandibular) for sleep apnea; Uvulopalatopharyngoplasty (UPPP) and palatopharyngoplasty (PPP); Laser Assisted Uvulopharyngoplasty (LAUP); Sleep apnea; Weight reduction surgery for OSA; Referral indications for sleep lab evaluation;

Dental: Dental services; Damage to Sound and Natural Teeth; Dental hospitalization; Dental implants; Oral appliances for the management of migraine headache syndromes, TMJ, OSA; Impacted teeth, extraction; Neuralgia-inducing Cavitational Osteonecrosis - Treatment; Removal of dental amalgams (fillings);

Dynamic Posturography; Electronystagmogram (ENG); Ernest or Eagle’s Syndrome/Stylomandibular Ligament Pain - Treatment with Radiofrequency Thermoneurolysis; Extracorporeal Shock Wave Lithotrypsy (ESWL) for Sialolithiasis (Salivary Stones); Frenulectomy; Impacted teeth - extraction; Intra-operative Electromyographic Monitoring of Cranial Nerves;

Ear: Myringotomy with Tympanostomy Tubes/Laser Myringotomy; Otitis media clinical guideline; Meniett 20 for overpressure treatment of Meniere's Disease; Hearing Tests; Oxygen Inhalation Therapy for Inner Ear Disorders; Electrocochleogram and perilymphatic pressure measurement;

Oral surgery: Oral biopsy for malignancy; Orthodontia; Orthognathic surgery; Application of interdental fixation device for conditions other than fracture or dislocation, includes removal; Mandibular condyle reconstruction with bone and cartilage autograft for hemifacial microsomia;

Mandibular hypomobility rehabilitation; Distraction osteogenesis for craniofacial abnormalities; Nasal endoscopy; Otitis media, recurrent; Otoplasty; Photodynamic therapy for advanced bronchial cancer

Radiofrequency ablation upper respiratory tissue; Rhinomanometry and acoustic rhinometry/Nasal Function Studies; Nasal turbninate procedures; Septoplasty; Septorhinoplasty; Sialendoscopy, therapeutic; Sialorrhea (drooling) - Surgical Treatment;

Sinuplasty; Sinusitis, acute; Sinus endoscopy, with or without computer-augmentation; Smell and Taste - Evaluation;

Streptococcal pharyngitis: Testing and antibiotics for adults at low-risk; Temporomandibular Joint Disorders (TMJ);

Thyroid surgery LOS; Tinnitus: Tinnitus Retraining Therapy; Transcutaneous electrical nerve stimulators (TENS) for severe tinnitus;

Tonsillectomy and/or adenoidectomy; Coblation non-thermal volumetric tissue reduction; Laser tonsillectomy

Zenker's diverticulum - repair;.

Meniere's disease - Transtympanic Gentamicin Injection for treatment of Meniere’s disease; Transtympanic Micropressure Applications/ Meniett 20 as a Treatment of Meniere’s Disease; Ultrasonic Surgery for Meniere’s;

Tracheal intubation; Tympanometry; Tympanostomy tubes; Vertigo; Vestibular Function Testing; Vestibular Rehabilitation; Canalith repositioning;

Laryngoscopy, Diagnostic; Vocal Cord Examination Using Videostroboscopy; Vocal Cord Injections to Prevent Recurrent Aspiration; ENT notes.

Gastroenterology:

Balloon Dilation of Gastrointestinal Tract Strictures; Breath tests for GI disorders; Capsule Imaging Endoscopy/Wireless; Celiac/Coeliac disease/Sprue; Colonoscopy, Direct & Virtual: screening, diagnostic;

Dialysis and related perfusion technology as treatment for hepatic failure; Hepatic failure, acute - albumin dialysis therapy; DNA test for colon cancer; Double Balloon Enteroscopy; Dysphagia - Evaluation of swallowing mechanism;

Electrogastrography (EGG); Endoscopy, upper gastrointestinal; Endoscopic Retrograde Cholangiopancreatography (ERCP); Magnetic resonance cholangiopancreatography (MRCP); Endoscopic Ultrasonography; Upper, Lower;

Esophagogastroduodenoscopy (EGD); Esophageal manometry; Esophageal pH monitoring; Injection sclerotherapy for variceal bleeding;

Fecal DNA Testing for Colorectal Cancer Screening and Monitoring; Fecal Occult Blood test, Screening; Fecal Incontinence - Transanal Radiofrequency Treatment; Fiberoptic Analysis of Colonrectal Polyps; Flexible sigmoidoscopy; Gastroesophageal reflux disease (GERD); Gastrophotography; Inflammatory bowel markers; Intestinal Rehabilitation Programs; Implanted Capsule pH Monitoring for GERD; Leukapheresis for inflammatory bowel disease; Motility disorders; Parotid tumors, malignant;

Photodynamic therapy for high grade esophageal dysplasia; Transendoscopic gastroplasty; Stretta and EndoCinch Procedures; Fecal Occult Blood test, screening - positive; Fiberoptic endoscopy for the evaluation of swallowing; Gastric freezing for the treatment of active peptic ulcers; Gastrostomy/PEG tubes; Hepatitis; Hepatitis B; Hepatitis C; Injection Sclerotherapy for bleeding esophageal varices; Gastric Pacing; Liver Biopsy; Liver assist or support devices; Motility Disorders: Upper GI - Diagnosis/Evaluation; Transesophageal Endoscopic Procedures for Gastroesophageal Reflux (GERD); Transjugular Intrahepatic Portosystemic Shunt; Transplantation; Urea breath testing for H. pylori infection; VitaStim for dysphagia;;GI notes.

General Surgery: Clinical Guidelines for Office-based Surgery; Anal sphincter, artificial; Attempted, aborted or non-completed surgical procedures - payment criteria; Co-surgeon, Assistant Surgeon, and Physician Assistant - payment criteria;

Anal fissure, chronic; Anorectal fistulal repair; Appendectomy; Bariatric surgery; Barrett's esophagus therapy;

Breast surgery (refer to the Plastic Surgery chapter for additional breast surgery guidelines) Breast biopsy; Breast ductal lavage; Breast reconstruction Post-mastectomy; Endoscopic axillary lymph node retrieval; Interstitial laser therapy for fibroadenoma of the breast; Mastectomy; Prophylactic mastectomy;

CMS 'never events' NCDs; Cholecystectomy, open or laparoscopic; Colon resection - Colectomy; Colostomy; Debridement, wound; Esophagectomy; Fecal incontinence - surgical therapy; Gastroesophageal Reflux Device Implantation/Implanted anti-gastroesophageal reflux device; Gastroesophageal Reflux (GERD) Surgery; Gender reassignment surgery; Hemorrhoidectomy - internal and external;

Hepatic resection/ablation for malignancy (Primary or secondary); Microwave ablation for liver metastases;

Hernia repairs: Athletic pubalgia or ‘sports hernias’; Hiatal hernia repair, Incisional hernia repair, Inguinal hernia repair, Tissue replacement for hernia repair; Umbilical hernia repair, Diastasis recti.

Incision and Drainage (I & D) Procedures; Laparoscopy or Peritoneoscopy; Morbid Obesity/Bariatric Surgery, Selection for surgery based on comorbid diabetes and hypertension in addition to BMI;

Wound management: Apligraft ® (Graftskin); Cutaneous Ulcers, Chronic/Wound Care; Debridement, Wound; Non-contact Normothermic Wound Therapy (NNWT); Vacuum-assisted wound closure; (Refer to the DME chapter for additional wound care guidelines)

Pancreatectomy, distal; Pre-operative tests; ‘Second Look’ surgical procedures; Thyroidectomy; Transabdominal artifical bowel sphincter implantation for faecal incontinence; Transanal rectal resection for obstructed defecation syndrome, stapled;

Post-op LOS by procedure, list; Inpatient Days Prior to a Surgical Procedure; Where should a higher-risk procedure be performed in a specific patient or population of patients? General surgery notes.

Hematology/Medical Oncology: Hem-Onc Authorization Guideline Notes; Adjuvant Chemotherapy; Adoptive immunotherapy (AIT); Anti-emetic therapy; Antineoplaston therapy; Blood-brain barrier disruption by osmotic agents - coverage; Bone marrow/Stem cell transplant (BMT); Chemotherapy; Umbilical cord blood compatibility testing; Chemoresistance assays/Tumor chemosensitivity; Colorectal cancer therapy; Colon cancer - KRAS Gene Mutation Test; Cryosurgical ablation hepatic lesions; Dendritic cell immunotherapy for cancer; Donor Lymphocyte/Leukocyte Infusions;

Breast Cancer: Overview; Chemotherapy vs Endocrine Therapy for Metastatic Breast Cancer; Epithelial Cell Cytology in Breast Cancer Risk Assessment and High-Risk Patient Management; Gene expression profiling for breast cancer treatment management; Microwave Thermotherapy for Breast Cancer; Extracorporeal Immunoadsorption; Interstitial laser therapy (ILT) for breast tumors;

Extracorporeal Photopheresis; Extreme Drug Resistance assay; Gene mutation assay for the diagnosis of myeloproliferative disorders; Hematopoietic colony-stimulating factor/Granulocyte-macrophage colony-simulating factor; Hemophilia therapy; Hyperalimentation for patients receiving chemotherapy; Hyperthermia; Hypothermia (regional scalp cooling) - chemotherapy-associated hair loss; Insulin potentiation therapy (IPT); Interleukin-2 (IL-2) Cancer Therapy;

Intrahepatic Chemotherapy for Liver metastasis - Chemoembolization; Intravenous iron; Isolated limb perfusion (ILP); Lung cancer; Mitoxantrone hydrochloride (Novantrone ®); Monoclonal antibodies for cancer therapy; Monoclonal Antibody (Mab) Imaging or Radioimmunoscintigraphy - colorectal cancer staging; Ovarian cancer, advanced; Photodynamic Therapy; Plerixafor Injection (Mozobil); Radiofrequency tumor ablation; Radioembolization hepatic malignancies;

Therapeutic phlebotomy; Transcatheter Arterial Chemoembolization; Vaccines to treat various cancers; Cancer-related web sites; Photodynamic Therapy; Thrombotic thrombocytopenic purpura, assay; Tumor cells, circulating in the blood, test coverage; Vaccines to treat cancer; Vitamin B12 Injections; Hem-Onc notes.

Laboratory: Medicare Coverage of Laboratory Testing; Cancer screening tests; Cardiovascular risk evaluation tests; Celiac disease lab testing; Cholesterol screening tests; Unnecessary tests; Employer-mandated tests and procedures; Diagnostic & screening tests: indications, coverage (HIV, Polymerase chain reaction (PCR) testing, PSA, Thyroid tests); Collagen cross links as markers of bone turnover; Digoxin levels; Hemoglobin A1c or Glycohemoglobin and Glycated Protein Tests; High Sensitivity C-Reactive Protein (hsCRP); Diabetes screening tests - criteria; Microalbuminuria; Antibody Tests for Neurologic Disease; Flow Cytometry;

Genetic Testing: Cytogenetic studies; First-trimester noninvasive screening for chromosomal abnormalities; Genetic/Molecular Susceptibility Screening/Testing/Counseling; Genetic screen for thyroid carcinoma and MEN; Genetic screen for breast and ovarian cancer (BRCA1, 2); Gene Expression Profiling for Managing Breast Cancer Treatment; Genetic testing for cystic fibrosis; Genetic testing for hereditary nonpolyposis colorectal cancer; Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer’s Disease; Genotyping for cytochrome P450 polymorphism;

Hair analysis; Heavy metals and other minerals, test indications; Hemoglobin A1c testing, rapid; Histocompatibility (HLA) testing; Human Chorionic Gonadotropin (hCG) Tests; Human tumor cell assays - Flourescent Cytoprint assay; Extreme drug resistance assay;

Immune cell function assay; Ionic calcium; Iron/Ferritin Studies, Serum; Lipid Profiles/Testing; Lyme Disease Testing; Lymphocyte Mitogen Response Test; Magnesium, serum; Parathyroid hormone testing; Partial Thromboplastin Time (PTT); Prothrombin time tests, home; Screening tests; Tumor markers; Urinalysis for volatile organic compounds; Urine culture, bacterial; Venipuncture, nonroutine; Laboratory References, general; Laboratory notes.

Miscellaneous: Assisted Suicide; Autopsies; Body composition measurements; Cryoanalgesia and Cold Laser (low-energy) Therapy for wound healing, pain therapy, and other disorders; Complications following Non-covered Services - Coverage; Death-related Services; Coverage of shipboard and out-of-US medical care;:

Electrosleep Therapy; Experimental/Investigative Services; Histamine desensitization therapy for intractable headache; Hospital Admission Guidelines for Diabetic Adults; Hospital charges for noncovered services; Humanitarian Device Coverage; Hyperbaric Oxygen Therapy;

Immunizations, influenza immunization; Injectable Medications; Laser procedures; Leeches - therapeutic indications; Miscellaneous Services - Medicare Basis for Payment Denial; Multiple Chemical Sensitivity Syndrome or Idiopathic Environmental Intolerances (IEI); Organ and Tissue Transplantation - bone marrow, intestinal, solid organs (kidney, liver, intestine, other); Outmoded tests and procedures (table);

Pain rehabilitation programs; Outpatient Hospital Pain Rehabilitation Programs; Pre-operative Hospital Admissions; Inpatient pain rehabilitation; Palliative care guideline links;

Physician's Office within an Institution--Coverage of Services and Supplies Incident to a Physician's Services; ‘Second opinions’; Sleep disorders- testing; Telehealth services; Transportation, medical/Ambulance transports; Notes.

Nephrology:

Nephrology Consultation/Referral for ongoing care; Dialysis Therapy For Renal Failure; Peritoneal dialysis catheter insertion; Laboratory tests for CAPD; Arteriovenous fistulae for dialysis; ESRD Hospital Utilization; ESRD coverage issues; Erythropoeitin therapy; Intravenous Iron Therapy;

Acute dialysis; Hemodialysis for the treatment of hepatorenal syndrome; Albumin dialysis for the treatment of acute-on-chronic liver failure; Hemodialysis for the treatment of schizophrenia; Ultrafiltration therapy for heart failure;

Kidney transplantation; Lymphocyte Immune Globulin/Anti-thymocyte Globulin;

L-carnitine supplementation; Renal disease education services, coverage; RenalVysion test; Nephrology web sites; Nephrology notes.

Neurology/Neurosurgery: Alzheimer Disease; Aneurysm, intracerebral, screening indications; Antibody tests for neurologic disease; Autogenous epidural blood grafts; Autism and Other Pervasive Developmental Disorders; Sensory Stimulation for Coma; CNS/Brain tumors; Guillain-Barre syndrome (GBS): Therapy;

Intra-epidermal Nerve Fiber Density Measurement; Epidural adhesions; Indications and recommendations for intracranial endovascular neurointerventional procedures - Table; Dystonia, Cervical - Selective Peripheral Denervation; Posterior tibial nerve stimulation; Nystagmus;

Electrical stimulation therapies in neuromuscular disorders: Facial Nerve Paralysis (Bell's Palsy) - Electrotherapy; Cerebral palsy; Spinal Cord Injury; Sacral nerve stimulation for urge incontinence, urinary retention; Stroke; Cranial Electrical Stimulation/Electrosleep Therapy

Neurology Studies: Autonomic Nervous System Function Testing; Brain death, diagnosis; Electroencephalogram (EEG) - standard, ambulatory, sleep-deprived, surgical, video; EEG telephone transmission coverage; Electrocorticography (ECoG); Brain mapping or Quantitive EEG for the diagnosis of psychiatric disorders; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV); Surface EMG; Facial nerve paralysis/Bell's palsy; Neuromuscular junction testing by repetitive stimulation; Stroke and other CNS Disorders; Somatosensory Evoked Responses, Vision Evoked Response test (VER), Vision Evoked Response test (VER); Anal or Urethral Sphincter Electromyography; Sensory Evoked Potentials; Multiple Sleep Latency Test (MSLT); Neuropsychological Testing (NPT);

Headaches; Cervico-occipital headaches - related procedures; Dihydroergotamine (DHE); Histamine desensitization therapies; Neuroimaging for headache - indications;

Multiple Sclerosis (MS) - Therapy, Web Sites;

Selective peripheral denervation (Bertrand procedure) for spastic torticollis; Spinal tap, diagnostic, Stereotactic Cingulotomy, for severe and intractable pain due to terminal cancer; Sympathetic therapy for chronic pain management; Sympathetic therapy for chronic pain management; Sympathectomy, Thoracoscopic; Transcranial Doppler Ultrasonography; Transient Ischemic Attack (TIA) - Hospitalization Indications; Trigeminal Neuralgia, Cryosurgery; Epiduroscopy;

Parkinson's Disease/Movement Disorders - Deep brain thalamic stimulation, for the treatment of intractable tremors; Fetal tissue Cell (mesencephalic, adrenal-brain and fetal xenograft) transplantation for the treatment of Parkinson’s disease; L-Dopa therapy; Pallidotomy for the treatment of Parkinson's disease; Thalamotomy for movement disorders;

Seizure therapies - Electroencephalographic biofeedback for intractable seizures; Surgical evaluation for intractable seizure disorders - Grid monitoring; Ketogenic diet for the control of intractable seizures in children; Vagus Nerve Stimulation for the treatment of refractory seizures;

Carpal Tunnel Syndrome - conservative therapy; Carpal Tunnel Release;

Embolization of intracranial aneurysms; Electromyelogram (EMG)/Nerve Conduction Velocity (NCV);

Diabetic Neuropathy: Peripheral neuropathy with loss of protective sensation (LOPS); H-wave stimulation for the management of chronic diabetic peripheral neuropathy; Decompressive surgery for diabetic neuropathy

Cognitive Rehabilitation Therapy; Sensory Integration Training; Constraint-induced movement therapy (CIMT); Head injury; Hippotherapy/Therapeutic Horseback Riding/Equestrian Therapy; Hypothermia following acute brain injury; Induced Lesions of Nerve Tracts;

Intra-operative Electromyographic Monitoring of Cranial Nerves; Invasive Intracranial Pressure Monitoring; NeuroControl Freehand System; Shunt, subcutaneous lumber; Stroke prevention - Angioplasty of intracerebral arteries; Stroke units; Thalamotomy for movement disorders;

Ulnar Nerve Transposition, Decompression or Release; Vagus Nerve Stimulation for the treatment of depression; Videopupillography/Tropicamide Drop Test for the Diagnosis of Alzheimer's Disease; Perception Threshold/Sensory Nerve Conduction Threshold (SNCT); Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain; Neurology/Neurosurgery notes.

Nuclear Medicine: Bone scan; CEA scans; Cardiac Scans - Introduction/Overview, Medicare LMRP; Cardiac scans - thallium and gated pool scans; Cerebral Scintigraphy for Brain Death; Cholecystokinin Cholescintigraphy/Hepato-biliary scintigraphy; Gastrointestinal scintigraphy; Gated Pool Scan; Liver spleen scan; Monoclonal Antibody (Mab) Imaging/Radioimmunoscintigraphy including Scintimammography; Octreoscans; Parathyroid scintigraphy;

Positron Emission Tomography (PET scans); PET-CT Fusion Studies; Pulmonary Scintigraphy; Prostate cancer staging scan; Renal Scintigraphy; Scrotal scintigraphy; Sentinel Lymph Node - Detection, Biopsy; Melanoma/Breast Cancer Staging;

Scans for Infection and Inflammation; Gallium scans; Indium-III Oxine labeled white blood cells scan; SPECT scans;

Thyroid studies; Tumor Scintigraphy (Gamma Camera); Nuclear medicine notes.

Nutritional therapy: Nutrition Counseling/Educational Programs; Specialty foods, Liquid nutrition products; Ketogenic diet counseling for refractory seizure control; Low protein food products; Renal insufficiency diets; Renal stone disease diets; Very low fat diets to treat or prevent atherosclerotic cardiovascular disease; Supplemental Fasting Regimens; Enteral Nutrition/Tube feeding;

Parenteral nutrition/Total Parenteral Nutrition (TPN); Telehealth services, nutritional; Internet resources for food and nutrition; Nutritional notes.

Obstetrics/Gynecology: Ablation - cervical lesion; Abortion/pregnancy termination - multiple gestation reduction; Amniocentesis; Cervical cancer; Cervical cerclage; Cervicography (cervigram); Cesarean section - elective; Chlamydia screens; Chorionic villus sampling; Colposcopy; Direct access for OB/GYN services; Dilation and Curettage (D & C), D & C plus hysteroscopy, D & C, Hysteroscopy plus pelvic laparoscopy - same day;

Endometrial endoscopic ablation for menorrhagia, including microwave, thermal balloon, cryosurgery, photodynamic; Endometriosis; Endometrial cancer screening and diagnosis;

Family Planning Services - Birth control devices; IUDs; Essure - Intrafallopian tube device; Depo-provera; Norplant, Oral contraceptives; Emergency or post-coital contraception; Natural family planning; Sterilization - tubal ligation/vasectomy, OTC products;

Fetal fibronectin testing for preterm labor and delivery risk; Fetal Monitoring, electronic; Fetal surgery for prenatally diagnosed malformations; Fetal screening for chromosomal abnormalities; Infertil - Fallopian tube recanalization; Falloscopy

Genetic Counseling and Testing; Gravlee Jet Washer; Home births; Hysterectomy; Outpatient hysterectomy; Hysteroscopy/Hysterosonography; Immunotherapy to decrease the risk of spontaneous abortion; Induction of labor;

Infertility management - Coverage criteria for females, Coverage criteria for males, Infertility treatment, Artificial insemination, Ova sticks - ovum transfer/uterine lavage - sperm donor/storage/washing; Intracytoplasmic sperm injection; In-Vitro Fertilization (IVF) and Gamete Intra-Fallopian Transfer (GIFT); Multifetal pregnancy reduction (MFPR); Ovarian diathermy; Recurrent Pregnancy Loss;

Transcervical balloon tubuloplasty; Intra-uterine device (IUD) - removal, Laparoscopy - pelvic; Nerve Ablation Procedures for Dysmenorrhea, Laparoscopic; Oophorectomy; Papanicolaou tests/‘Pap smears’ with HPV DNA Testing for Cervical Cancer; Pelvic Congestion Syndrome - Ovarian and internal iliac vein embolization; Perineorrhaphy; Preimplantation Genetic Diagnosis; Pregnancy; Premenstrual syndrome (PMS) evaluation and treatment; Progesterone (17P) for high-risk pregnancies to prevent preterm delivery; Prolapse, vaginal;

Salivary estriol test for preterm labor; Referral guidelines to Ob/Gyn; Salpingectomy/salpingostomy; Tocolytic therapy for the prevention of preterm delivery; Transvaginal ultrasound; VABRA aspirator; Ultrasonography in pregnancy; Ultrasonongraphy screen for Down Syndrome; Uterine Activity Monitoring, home (HUAM), Uterine Fibroid (Leiomyomata) Surgical Therapy; Uterine artery embolization for the treatment of fibroids; Uterine nerve ablation (UNA); VABRA aspirator; Zinc blood levels in pregnancy; Ob/Gyne notes.

Ophthalmology: A-scans, B-scans; Blepharoplasty, ptosis correction and eyelid reconstruction;

Cataract surgery: Capsulotomy; YAG laser; Cataract surgery procedures; Accommodating/Presbyopia-correcting IOL coverage; Preoperative Evaluation and Testing for Cataract Extraction; General anesthesia for cataract extraction procedures; Endothelial cell photography; Cataract section references and links;

Conjunctivitis; Conjunctivodacryocystorhinostomy; Balloon Dacryocystoplasty/Dacryoplasty for Nasolacrimal Duct Obstruction; Contact Lenses;

Cornea: Corneal abrasions, patching; Computer-assisted corneal topography; Corneal graft utilizing amniotic membrane transplantation (AMT); Corneal implants; Corneal hysteresis; Corneal pachymetry; Corneal post-transplant wound revisions; Corneal wedge resection; Corneal remodeling procedures - Refractive Keratoplasty/Radial Keratotomy/Phototherapeutic Keratectomy; Hydrophilic contact lens; Refractive Keratoplasty/Radial keratotomy; Keratoconus; Keratoplasty; Keratoprosthesis or Artificial Cornea; Keratoprosthesis, Hydrogel;

Diabetic retinal disease; Telescreening for diabetic retinopathy;

Entropion; Ectropion; Enucleation; External Ocular Photography; Eye Examinations - Medicare; Routine vision exam; Fundus photography;

Glaucoma treatment; Optic Nerve Head Topography - Confocal Laser Scanning Tomography, Stereophotogrammetry; Argon Laser Trabeculoplasty; Aqueous drainage/shunt implants for refractory primary open-angle glaucoma;

Gonioscopy; Gold Weight Upper Eye Lid Implants; Grave’s Disease Ophthalmopathy; Indocyanine Green Angiography; Iridotomy/Iridectomy;

Age-related Macular Degeneration (AMD); Macular degeneration: Laser Therapy; Radiation Treatment; Lucentis™ (Ranibizumab) Intraocular Injection for AMD; Macular Fovea Translocation for AMD; Ocular Photodynamic Therapy (OPT) - Visudyne (Verteporfin) Therapy for Age-related Macular Degeneration; Macugen® Treatment of Wet Age-Related Macular Degeneration; Prism spectacles for ARMD; Transpupillary Thermotherapy for ARMD;

Macular holes (retinal holes); Nasolacrimal duct dilation, probing; Ocular blood flow tests; Opthalmoscopy, extended with retinal drawing Orbitotomy; Photocoagulation; Pterygium; Ptosis; Punctal dilation/snipping; Punctal Plugs and Punctoplasty for ‘Dry Eyes’ Syndrome; Prosthesis, eye; Refraction/routine eye exams;

Retina, artificial; Retinal detachment; Retinal Photocoagulation, Laser - Destruction of Localized Lesions of Retina; Retinal vein occlusion therapy;

Scleral buckle; Scleral shell; Strabismus correction; Suprachoroidal injections; Tarsorrhaphy; Thyroid eye disease - treatment options; Transpupillary Thermal Therapy (TTT); Uveitis - Intravitreal implants;

Viscocanalostomy; Visual Field Testing; Vision training (Orthoptics); Vision therapy for the treatment of learning disabilities; Visual Rehabilitation Program; Vitrectomy; Referral criteria summary sheet/grid for common complaints; Ophthalmology notes.

Pediatric:

Pediatric authorization guidelines for Lengths of stay; Apnea monitor; Bronchiolitis, indications for admission; Circumcision of the newborn male; Cord blood testing; Cystic fibrosis screening in newborns;

Diabetes mellitus - Assessment of need for hospitalization for the stabilization of newly diagnosed children with diabetes; Diabetes Management Using ‘Hepatic Activation’ or ‘PIVIT’ Therapy;

Comprehensive pediatric case management services; Diarrhea and vomiting in Children < 5 Years - Diagnosis and treatment Guideline - link; Early Intervention Programs; Extracorporeal membrane oxygenation (ECMO);

Hearing Screening, Newborn; Immunizations, Lead screening - blood - children; Newborn LOS - when infant healthy, Mother requires continued hospital care; Newborn Medicaid coverage; Phototherapy; Physician attendance at delivery for evaluation and management of newborn; Port Wine Stains; Indications for referral - links; Preventive care; Child Health Advice Links for the Layperson; Pediatric notes.

Pharmacy:Pharmacy benefits; State of California Knox-Keene act requirements; Canadian drugs; Formulary; MAC pricing; Generic substitution; Alpha 1-antitrypsin inhibitor therapy; Anticoagulant Therapy - Monitoring; Biologicals; Hepatitis vaccines; Growth hormone replacement (adults and children); Botulinum toxin; Calcitriol; Cancer chemotherapy;

Enzyme-replacement therapy for lysosomal storage disorders; Erythropoeitin (EPO) Therapy; Experimental Drug Therapy; Chelation therapy; Diabetes management therapy/supplies; Diabetic foot ulcers - Regranex gel therapy; Gonadotropin-releasing hormone therapy; H. pylori testing and therapy; HIV Drug susceptibility and resistance testing; Human C1 Inhibitor (Cinryze); Hyaluronidase, intra-articular injections;

Infliximab (Remicade) therapy - indications; Insulin, inhaled; Insulin, intermittent IV; Intravenous immunoglobulins (IVIG); IVIG to prevent RSV; Cytomegalovirus Immune Globulin Intravenous, Human (CMV-IVIG);

Interferon therapy; Interleukin-2 (IL-2) for HIV Therapy; Intrathecal Baclofen for spasticity; Intravenous histamine therapy; Intravenous iron therapy; Iontophoresis - applications in transdermal medication delivery;

Low molecular weight heparin; Lyme disease vaccine; Meningococcal vaccine; Mifepristone (Mifeprex™, RU 486); Nebulized beta adrenergic agonist therapy for lung diseases; Nesiritide (Natrecor®) for heart failure; Nicotine patch, gum or nasal spray therapy for smoking cessation; Off-label drug therapy; Oral contraceptives; Phonophoresis; Prior authorization list w/indications; Platelet-derived Growth Factor for Wound Healing (Regranex, Procuren); Prophylactic antibiotics; Prostacyclin infusion therapy;

RA and related conditins - drug therapy issues; Self-administered drug list; Sexual function therapy; Smallpox Vaccination; Topical steroids; Transfer Factor; Tumor Necrosis Factor Inhibitors/Biologic Response Modifiers; Injectable drugs; Pharmacy web sites; Pharmacy notes.

Plastic & Reconstructive Surgery: Abdominoplasty/Panniculectomy;

Breast surgery - Implant removal and/or replacement; Gynecomastia reconstruction in the male patient; Augmentation mammoplasty; Reduction mammoplasty or breast reduction surgery; Mastopexy; [Additional breast surgery guidelines in the General Surgery chapter].

Liposuction: Lipectomy, Suction-assisted;

Cosmetic surgery; Chemical exfoliation or peel; Cosmetic laser surgery; Cutaneous Ulcer, Chronic - Electrical Stimulation; Ear lobe deformities; External ear reconstruction; Hair transplantation; Mentoplasty (Chin Augmentation, Genioplasty); Plastic Surgery to Correct "Moon Face"; Porcine Skin and Gradient Pressure Dressings; Septoplasty, Septorhinoplasty, Rhinoseptoplasty, Rhinoplasty;

Reconstructive surgery - general criteria; Scar revisions; Skin redundancy following massive weight loss; Skin Substitutes for the Treatment of Thermal Injuries; Plastic & Reconstructive Surgery notes.

Pulmonary:

Pulmonary function tests (Vital capacity, Blood gases, Pulse Oximetry, Overnight home-based oximetry, Spirometry, transtelephonic spirometry, Lung volumes, Metacholine challenge, Diffusion capacity, Lung compliance; Exhaled Nitrous Oxide, Cardiopulmonary exercise testing) Quantitative pilocarpine iontophoresis sweat test; Cryotherapy for malignant endobronchial obstruction;

Electrophrenic Pacemaker/Diaphragmatic/Phrenic Nerve Stimulator; Exhaled nitric acid testing for respiratory disorders; Fiberoptic bronchoscopy; Heat Treatments - including diathermy and ultrasound for pulmonary conditions; Inhaled nitric oxide for hypoxic respiratory failure; Lung volume reduction surgery; Nebulized beta adrenergic agonist therapy for lung diseases; Sleep apnea studies/Polysomnography; Sleep apnea studies, portable; BiPap; Actigraphy testing;

Pleurodesis with talc poudrage in malignant pleural effusion; Phrenic nerve pacing/Diaphragm pacing; Positive Expiratory Pressure (PEP) for Cystic Fibrosis Therapy; Noninvasive Positive-Pressure Ventilation (NPPV) for COPD; Pulmonary embolism - LOS;

Hospital Admission criteria: COPD admission criteria; Pneumonia admission criteria; Avoidable hospitalizations for COPD and pneumonia;

Respiratory Therapy Services; Postural Drainage Procedures and Pulmonary Exercises; Pulmonary Rehabilitation; Outpatient Pulmonary Rehabilitation (PR); Pulmonary teaching and training; COPD guideline resources and links; Smoking cessation benefits; Total body plethysmography; Tracheo-bronchial stents; 'Virtual' Lung Scans; American Association of Respiratory Care: Clinical Practice Guideline Links; Pulmonary notes.

Radiology: Documentation requirements; Imaging guidance during surgical procedures; Bone Mass Measurement/Bone mineral density (BMD) testing; Skeletal surveys in children; Cardiac scans for CAD; Cerebral angiography; Chest x-rays, routine; Contrast media;

Spine - diagnostic radiology in adults and children; Imaging studies in acute low back pain; Myelography and Cisternography; Discography; Scoliosis in children - indications for radiography; Epidurogram/Epiduroscopy; Sacro-iliac joint arthrography; Videofluoroscopy of the spine (Motion X-rays).

Breast imaging studies: Diaphanography of the breast; Mammography, screening or diagnostic/Digital/CAD mammography; Magnetic Resonance Imaging of the Breast: Differential Diagnosis; Breast Ultrasound and Echography; Stereotactic Breast Biopsy;

Diagnostic radiology - general; Extremity x-rays; Knee trauma; Skull x-rays, post-trauma (children); Diagnostic Arteriography - Indications; Cervicocerebral angiography; Digital subtraction angiography (DSA); Infusion Venography; Resources for Angiography Indications; Abdominal and Gastroenterological X-ray Procedures; Cholescintigraphy (HIDA); Cinedefecography; Herniography; Urological: Intravenous Pyelography (IVP); Cystography and Urethrography; Voiding cystourethrography in Children;

MRI and CT scans - Computerized Tomography (CT) or Computerized Axial Tomography (CAT) - Overview; Whole body CT scans; CT angiography; Computerized Tomography (CT or CAT) including extracranial head, brain, and thoracic scans; High-resolution CT (HRCT) for Pulmonary Studies; CT for appendicitis; Spiral CT Scans for Lung Cancer Screening; Helical CT for Pulmonary Embolism Detection; Computerized Axial Tomography (CT) Scans: Pelvis, Abdomen, Abdomen and Pelvis - on the same day; Electron-beam CT screening for coronary artery disease;

MRI Studies - Overview; ‘Standing’ and ‘Sitting’ MRI Scans; MRI Brain; MRI Peripheral Nerves, MRI Orbit, Face, and Neck; MRI Breast; MRI Spine; MRI/MRA - Cardiovascular studies; MRI Extremities; MRI Abdomen and Pelvis; Tumor staging; Table citing optimal imaging studies by region; CT Angiogram; MRI and CT-guided biopsies; Magnetic Resonance Angiography (MRA) including Venography; Magnetic Resonance Neurography; Magnetic resonance spectroscopy/Nuclear magnetic resonance; Magnetic Source Imaging (MSI)/Magnetoencephalography (MEG);

Neuroimaging Studies for Headaches; Metastatic bone disease - radiologic evaluation; Percutaneous Drainage/Aspiration of Abscesses and Fluid Collection; Percutaneous Permanent Inferior Vena Cava Placement; Percutaneous Transcatheter Embolization; Percutaneous Transluminal Angioplasty (PTA);

Peripheral Vascular Disease Evaluation; Renal Artery Stenosis - Angiography and Stent Placement; Spiral CT for Lung Cancer Screening; Stent placement for vena caval obstruction; Thermography; Portable Hand-held X-ray Device;

Ultrasonography: Overview; Noninvasive cerebrovascular studies of extracranial arteries; Paranasal sinus ultrasonography; Spinal canal and contents ultrasonography; Peripheral Arterial Ultrasound Examination Using Pulsed Doppler; Peripheral Venous Ultrasound Examination; Thyroid and Parathyroid Ultrasonography; Transcranial Doppler Ultrasonography; Transvaginal ultrasound;

Bladder ultrasound/post-void residual urine; Transrectal ultrasound for prostate or rectal cancer - biopsy/staging; Pelvic Ultrasound in Females; Sonohysterosalpingraphy; Obstetrical Ultrasonography; Scrotal Ultrasonography; Retroperitoneal Ultrasonography; Developmental Hip Dysplasia Detection by Ultrasonography; Ultrasound of peripheral sites (tibia, phalanges) for the selection of patients for pharmacologic treatment of osteoporosis;

Radiology Benefit Management; Radiology guideline resources/web links; Radiologist orders; Radiology notes.

Radiation Therapy/Oncology: Radiation oncology; Combination Chemotherapy and Radiation Therapy; Criteria for Inpatient Admission for Radiation Therapy;

Brachytherapy; Brachytherapy for the Prevention of Restenosis in Peripheral Arteries Following PTA of the Femoropopliteal System; Intracoronary Brachytherapy; Breast Conservation Therapy in the Management of Invasive Breast Cancer;

Hyperthermia; Intraoperative radiation therapy; Neutron Beam Radiotherapy; Proton Beam Radiotherapy; Selective Internal Radiation Therapy (SIRT); Stereotactic radiosurgery; Transperineal Brachytherapy for prostate cancer; Boron Neutron Capture Therapy (BNCT) For Glioblastoma Multiforme; Intensity Modulated Radiation Therapy (IMRT); Radiation Therapy web sites; Notes.

Skeletal-muscular System Referral guideline links; Rheumatology referral guideline; Autologous blood injections for tendinopathy;

Bone grafts/fillers: Bone morphogenetic protein grafts; Pro ostron porous hydroxyapatite bone graft substitute; platelet rich plasma; Porcine intestinal submucosa surgical mesh; Bone void fillers for non-unions; Bone cementoplasty;

Cervical discs, artificial; Coblation non-thermal volumetric tissue reduction;

Knee region: Arthroscopy - knee; Arthroscopic lavage or debridement, knee; Total Knee Replacement; Chondrocyte Implantation, autologous/cultured & Meniscal Transplantation; Hyaluronidase, intra-articular injections for osteoarthritis; ‘Healing Response Surgery’ for ACL Repair; Meniscectomy; Unicondylar Interpositional Spacer;

Foot and ankle: Bunionectomy; Chondrocyte transplantation, ankle; Foot care - routine; Mycotic nails; Other covered services for the foot and ankle; Ingrown toe nails; Olecranon bursa aspiration; Plantar Keratosis; Plantar fasciitis and heel spurs; Consultation services by a podiatrist - skilled nursing facility; Fractures of the toe; Hammertoe surgery; Interdigital neuroma; Maxwell-Brancheau Arthroereisis (MBA) Implant - for flat-foot; Metatarsal Phalangeal Joint Replacement; Pedography; Silicone injections for podiatric conditions; Skin substitute for non-infected venous stasis or Diabetic Foot Ulcer Treatment; Ankle sprains/strains; Total ankle replacement.

Back and Neck: Acute cervical pain; Artificial Intervertebral Disc; Laminectomy ; Low back pain; Machines to test and treat low back pain; Chymopapain Chemonucleolysis; Endoscopic Anterior Spinal Surgery; Epidural adhesions - neurolysis; Epidural injection of steroids for back pain; Facet Joint Injections; Paravertebral Nerve Blocks; Facet Denervation, Facet Denervation: Neurotomy, Facet Rhizotomy, or Articular Rhizolysis; Facet Denervation: percutaneous radiofrequency; Hypertonic saline for the treatment of epidural adhesions, adhesive arachnoiditis, or failed back syndrome;

Implantable Infusion Pumps for the Treatment of Chronic Severe Back Pain; Interspinous distraction procedures for lumbar stensosi; Intradiscal Electrothermal Therapy (IDET); Laminectomy; Laser assisted spinal endoscopy; Lumbar fusion; Magnets; Meniscectomy; Microdiscectomy; Neuroreflexology;

Percutaneous Lumbar Discectomy, including laser procedures; Percutaneous vertebroplasty and kyphoplasty; Prolotherapy; Metastatic spinal cord compression; Sacro-iliac joint arthrography, injections; Scoliosis surgical indications; Spinal instability, lumbo-sacral - Pedicle screw fixation; Spinal Instability, cervical - lateral screw fixation; Spinal stenosis; Sacro-iliac Joint Injections;

Chiropractic Medicine & Services: Craniosacral therapy; Cranial laser release therapy (CLRT); Myofascial release; Spinal manipulation under anesthesia;

Shoulder: Shoulder Arthrography; Arthroscopy, shoulder; Electrothermal arthroscopic repair for shoulder instability; Impingement Syndromes, Shoulder Bursitis, Rotator Cuff Tendinitis & Tears; Ultrasound therapy for calcific tendinitis of the shoulder;

Wrist, Hand, Fingers: Carpal tunnel syndrome; finger joint implants; Trigger finger - therapy

Hip: Hip resurfacing; Open femoro-acetabular surgery for impingement syndrome; Steroid Injections for Osteoarthritis of the Hip; Total Hip Replacement (THR) - Primary, excluding hip fracture, indications, LOS;

Other Skeletal-muscular: Distraction osteosynthesis, Ilizarov method; Electrothermal capsular shrinkage; Extracorporeal Shock Wave Therapy (ESWT) for musculo-skeletal conditions; Apligraft ® (Graftskin); Carpal tunnel release; Sacro-iliac fusion; Trigger Point Injections;

Bone stimulators, electrical and low-intensity ultrasound; Gait analysis or the electrodynogram; Ganglion cysts; Aspiration/Injection Therapy: tendon sheath, ligament, or trigger points or ganglion cyst; Aspiration/Injection Joints; Osteoarthritis management;

Osteogenic protein-1 for the treatment of nonunion fractures; Osteoid osteoma - thermal therapy; Rheumatology referral guidelines; Titanium rib implants; Skeletal-muscular system notes.

Urology: Referral guidelines; Circumcision of the adult male;

Bladder: Therapy for bladder cancer; Cystectomy; Urinary FISH Test for Recurrent Bladder Cancer; Valrubicin for carcinoma in-situ of the bladder; Bladder stimulator/Pacemaker implantation; Bladder pacemakers; Bladder Capacity Ultrasound (Post-void Residual Measurements); Cystoscopy; Bladder biopsy, transurethral; Interstitial cystitis - DMSO, other therapies; Neurogenic bladder treatment;

Impotence/Erectile dysfunction (ED) Evaluation and treatment; Cavernous Nerves Electrical Stimulation with Penile Plethysmography; Dynamic infusion cavernosometry and cavernosonography; Viagra; Noninvasive suction devices; Papaverine injections; Penile prosthesis implantation; Electroejaculation; Internal Pudendal Arteriography (Angiography) for Erectile Dysfunction; Testosterone therapy for ED; Sural nerve grafts in association with radical prostatectomy;

Prostate: Prostate Cancer therapy; Prostate Cancer Screening Tests and Procedures; Cryotherapy; Robot assisted radical prostatectomy; Laser prostatectomy; Prostate Specific Antigen (PSA); Gene-based tests for prostate cancer;

Benign Prostatic Hypertrophy - Treatment options; Balloon dilation; UroLume® endourethral prosthesis (urethral stent) for BPH, stenosis, strictures; Cryosurgical ablation of the prostate; Microwave therapy for BPH; Transrectal ultrasound for prostate cancer - biopsy/staging;; Transurethral Resection of the Prostate (TURP); Transurethral Microwave Thermotherapy (TUMT) for BPH; Transurethral Radiofrequency Thermotherapy/Needle Ablation of the Prostate (TUNA); Transurethral electrovaporization of the prostate (TUVP); Water-Induced Thermotherapy (WIT);

Shock wave lithotripsy (Extracorporeal shock wave lithotripsy or ESWL): ESWL for renal stones; Extracorporeal shockwave therapy for Peyronie's disease.

Incontinence - defined/introduction [refer to the OB/Gyn chapter for additional incontinence guidelines]; Artificial Urinary Sphincter; Behavioral therapies for incontinence; Electrical stimulation of the pelvic floor; Magnetic resonance therapy; Sacral nerve stimulation for urge incontinence; Transurethral/Periurethral collagen implantation for stress urinary incontinence; Marshall-Marchetti Kranz, Burch, Stamey and similar procedures; Stress urinary incontinence, male; Tension-free vaginal tape for incontinence; References - Urinary Incontinence;

Male infertility; Hyaluronan Binding Assay; Male hypogonadism; Varicocele repair - indications;

Peyronnie's disease - therapy; Percutaneous Nephrostomy; Renal Cryoablation; Renal cysts; Renal pyeloplasty; Transsexual surgery;

Ureteral stents; Urethral Dilation - female; Urethral Sphincterometry; Urethral Stents; Urodynamic Testing; Vasectomy, VasClip; Vesicoureteral reflux procedures; Urology notes.

Vascular Laboratory: Noninvasive cerebrovascular studies of extracranial arteries; Carotid function - non-invasive tests: Duplex scan of carotid arteries; vertebral arteries; Ocular Plethysmography (OPG) and Ophthalmodynamometry; Ultrasonographic measurement of carotid intimal-medial thickness as an assessment of subclinical atherosclerosis; Transcranial doppler, Penile doppler and Corpora Cavernosography, Peripheral arterial non-invasive studies: Segmental Doppler Pressures and Pulse Volume Recording; Exercise (Stress) Doppler Test; Visceral arterial duplex imaging; Peripheral Arterial Duplex Scan; Digital Arterial Evaluation; Peripheral venous and arterial non-invasive studies/ultrasonography; Peripheral Arterial Ultrasound Examination Using Pulsed Doppler; AcuTect/Scintigraphic Imaging For Detection/Localization of Lower Limb Deep Vein Thrombosis;· Hemorheograph; Vascular lab notes.

Addenda:

Operational Standards; Consultations with family members and significant others; Due diligence; Privacy Policy - example statement for patients; Delegation to primary providers; Periodic re-evaluation of pre-authorization policies - radiology example; Delegation to SCPs (table); New Medical Technology Assessment - Policy/Procedure, Noncovered services; Observation status for acute care - P&P; Inpatient Admission Changed to Outpatient - Medicare P & P; Performance standards: QI/UM/Provider relations/Customer service; Critical Care - Medicare LMRP; Worker’s Compensation;

Specialty Referral Guidelines for Diabetes Management/Inpatient Management Guideline;

Disability Ratings/Certifications with resources

Hospital care ‘length of stay’ targets/benchmarks or goals: by age range; Length of stay targets by DRG; NY State Medicaid ALOS by DRG, 2004; Surgical Procedure LOS benchmarks; Hospital volume-based referral strategies - relationship to LOS, readmissions; Intensive/Critical Care Unit (ICU or CCU) Length of Stay Database ( UK ); 23 hour observation lengths of stay by diagnoses, medical and surgical; Effect of the availability of post-acute care services on LOS; Outpatient procedures or ‘Same-day discharge’ list; Infections prolong hospital stays; Psychiatric comorbidity prolongs LOS; ICU LOS by physician and diagnosis not related to outcomes;

Co-surgeon, Assistant Surgeon, and Physician Assistant - Requirements for Payment with code list; Multiple surgical procedures - payment criteria; Global surgical care - payment issues; Metropolitan Height-Weight charts.

References and Resources: located throughout the manual - conveniently following each criteria or topic + a general references and resources section near the end of the manual; Guideline resources on the web - links to helpful resources.

Note: Review criteria guidelines or ‘benefit interps’ are useful resources for claims payment decisions to base medical necessity decisions, particularly when little or no preauthorization function or information exists as well as utilization management, educational and precertification tools. They should be distributed to relevant physicians and other providers for review, input and any needed change prior to implementation. All should be reviewed and approved by a Medical Policy Committee of the purchasing organization prior to use. Modification related to local clinical circumstances or terms of applicable certificates of coverage or provider contracts may be appropriate and necessary.

Behavioral Health, Physical, Occupational and Speech Therapy/Rehabilitation Care, Post-acute Care and Extended Care Services criteria as well as Utilization Management policies, procedures, forms and related issues are in separate manuals due to space limitations in this publication. Please refer to the pages listing Apollo manuals or the order sheet for price, shipping/handling, and other related ordering information.

Medical Review Criteria for Managing Care

Share this report

Other tasks

Research Assistance

Related Markets

Managed Care Reports

Free Alert Me service